Open Letter To James Hall/Request to re-open ValuJet 592 Investigation
cli...@cari.net
This letter has been posted on the Valujet592 Memorial website at
http://www.flight592.com/Flight592Discussion-Current/_disc5/00000152.htm
June 22, 1998
Santee, CA. 92071
Mr. James Hall, Chairman
National Transportation Safety Board
490 L'Enfant Plaza, S.W.
Washington, D.C. 20594
Via Facsimile (202) 314-6018
Re: Request to re-open ValuJet 592 Investigation based on air traffic
controller errors and the FAA's inaccurate heat and gas testing of the
fire in the DC-10 cargo compartment.
Chairman Hall:
My name is James A. Bergquist, former FAA air traffic controller. I
have read the NTSB Final Report on the Valujet 592 disaster and I was
compelled to write to you. I have detected several errors made by the
air traffic controller and his supervisor in the handling of the
emergency. Additionally, I have problems with the NTSB theory as to
the cause of the disaster, with the oxygen generator fire tests, and
with the "uncontrolled descent" theory.
On Page 172 of the NTSB Accident Report, at 14:10:32 VJ592 requests an
"immediate" return to MIA. The controller turned VJ592 from a heading
of 300 degrees to a new heading of 270 degrees, due west and away from
MIA. After the controller finds out the nature of the emergency, at
14:10:46, he has VJ592 remain on the same heading. According to a 3/98
Atlantic Monthly article located at
http://www.theatlantic.com/issues/98mar/valujet1.htm,
the controller then asked for a supervisor. At 14:11:07, he turns
VJ592 to a new heading of 250 degrees, still away from MIA, and gives
VJ592 clearance for a descent to 5,000 feet. At 14:11:11, VJ592 reads
back the wrong altitude (7,000 feet). By this time, the supervisor is
monitoring the position and both the controller and the supervisor
missed the erroneous altitude readback.
At 14:11:38, VJ592, still flying away from MIA, asked for the "closest
airport available". At 14:11:42, the controller responds and tells
VJ592 "They're going to be standing by for you" This transmission is
telling VJ592 that there is no closer airport than MIA. Worst of all,
the controller AND his supervisor still allowed VJ592 to continue on a
270 heading away from the airport. Then finally at 14:11:47 VJ592
asked for radar vectors. This was VJ592's third call for a turn back
to MIA. Then the controller AND his supervisor snap out of their
stupors and at 14:11:50, VJ592 was turned left to a heading of 140
degrees. That is one minute and 18 seconds after VJ592 first asked
for an "immediate" return to MIA. At 300 Kts., or about 6 miles per
minute, that is almost nine miles away from the airport and nine miles
back plus the time and distance it takes to turn around.
Now a larger problem surfaces. VJ592 would not have had to turn
around at all. At 14:11:38, MIA was no longer the closest airport
available. At that time, Dade-Collier Training and Transition (TNT)
was the closest airport. This airport has a 10,500 X 150 Ft. runway
with an Instrument Landing System (ILS) and approach lights. And VJ592
could have been safely on the ground at TNT in just two minutes, less
that half the time it would have taken to reach MIA.
TNT - DADE-COLLIER TRAINING AND TRANSITION AIRPORT
MIAMI, FL
Location
Lat/Long: 25-51-42.452N / 080-53-49.139W
(25.8617922 / 80.8969831)
From city: 36 miles W of MIAMI, FL
Control tower: no
14:13:27 Critter five ninety two descend and maintain three thousand.
Why is the controller giving VJ592 a descent to 3,000 ft. when both he
and his supervisor are watching the radarscope and can both see the
aircraft's true altitude of 900 ft.?
On the VJ Site Ground Track document at
http://www.flight592.com/NTSB/ground.htm
at 14:13:27, VJ592 was somewhere between 900-1700 ft.
14:13:43 Critter five ninety two opa locka airports about ah twelve
o'clock at fifteen miles
Finally the controller decides to tell VJ592 about a closer airport.
But at 14:13:43, VJ592 had already turned southbound and Opa Locka
airport would have been at her 10 O'clock. Was this controller and his
supervisor tested for drugs and alcohol?
I have seen controllers using drugs and days later get caught in a
"random" drug test only to have the results of the test come back
negative. I have seen controllers using drugs and alcohol on the job
for almost 30 years.
Just recently, a controller at MIA passed out in the bathroom of the
tower on heroin. The Hub Manager and the tower chiefs of MIA and FTL
were reassigned after it was learned that they were giving advance
warning of "random" drug tests. Additionally, two supervisors at MIA
were reassigned because they falsified attendance records to try and
show that the controller had gone home sick before the overdose in an
effort to cover up the incident.
I have been telling the FAA, DOT IG, the Congressional Aviation
Subcommittee, and the Whitehouse about my personal knowledge of on the
job druguse, advance warning of "random" drug testing, and the
falsification of attendance records for the past 10 years and nobody
did a thing about it. Now we have controllers using heroin on the
job.
I would like the NTSB to conduct a thorough investigation into the
backgrounds of the controller who was working VJ592, his supervisor,
and the controller who overdosed on heroin at MIA ATCT. I believe
there may be a connection between these incidents. I can think of no
other reason why the controller and his supervisor were in such a
stupor to make such critical errors.
Now I would like to address the testing of the oxygen canisters. On
page 53 (1.16.1), the NTSB final report states "A series of five tests
involving oxygen generators was conducted at the FAA's fire test
facility near Atlantic City, New Jersey, on November 6 and 7, 1996,
under the direction of the Safety Board. The tests were carried out
in an instrumented (72) and fire-protected DC-10 test chamber cargo
compartment with a volume of about 2,357 cubic feet. (As noted
earlier, the volume of the cargo compartment in the DC-9 airplane is
about 560 cubic feet.) The door to the cargo compartment was left
open for video recording purposes."
In (72) it states "The cargo compartment was instrumented with the
following: (1) multiple thermocouples for temperature measurements,
(2) a water-cooled calorimeter located about 40 inches above the floor
(the distance between the floor of the DC-9 cargo compartment and the
ceiling) and above the packaged oxygen generators, (3) continuous
oxygen measurements, (4) continuous carbon monoxide and carbon dioxide
measurements, and (5) smoke measurement."
Why did the FAA substitute a DC-10 cargo compartment when it is more
than 4 times the size of the DC-9s? Wouldn't a fire progress much
slower in a smaller cargo compartment? The smaller cargo compartment
would contain less oxygen. The FAA's test of the DC-10 compartment
would give the fire 4 times the oxygen initially to start. That is, of
course, providing the tests were conducted in a closed compartment.
Why was the door left open during the tests? How can anyone
accurately analyze a fire when a constant flow of fresh oxygen is
allowed to feed the fire? The report states that the door was left
open "for video recording purposes", but I have seen cameras inside of
race cars and wonder why a camera was not placed inside the
compartment. If the reason was the lack of visibility due to smoke,
then an infrared camera could have been used successfully. I have
seen fire departments use these cameras on television to demonstrate
how to search a smoke-filled building.
How can the FAA's instruments accurately measure heat, oxygen, carbon
monoxide, carbon dioxide, and smoke when the fire is drawing in fresh
oxygen and allowing the heat, gases, and visible smoke to escape
through an open door? The water-cooled calorimeter was placed 40
inches above the floor to duplicate the DC-9 ceiling but even if the
door were closed, the measurements would have been totally inaccurate
because the heat and gases would rise to the ceiling of the DC-10 and
the measurements at 40 inches above the floor couldn't duplicate the
measurements at the ceiling of a DC-9.
Why is the NTSB placing the blame on the FAA for their lax oversight
of Valujet on one hand and then turning around and allowing the FAA to
do the testing of the oxygen canisters which are at the very heart of
their investigation? Why didn't the NTSB question the accuracy of
these tests? This appears to be nothing more than a "Chinese Fire
Drill". I can't believe that your investigators would accept the FAA's
conclusions about the fire when they saw the FAA's flagrant disregard
for the test's accuracy.
On the Valujet site at http://www.flight592.com/NTSB/an.htm, an
anonymous Valujet mechanic called the cabin safety group three days
after the accident and reported that N904VJ was riddled with
electrical problems including problems on the day of the crash. He
also stated that some circuit breakers had been bypassed on the
aircraft. He did not call back. He did state that he had personally
replace 6 black boxes on the aircraft in the previous 30 days.
Valujet maintenance records would easily identify this mechanic. I
saw nothing in the final report about any electrical problems. Did
any NTSB investigators even attempt to find this anonymous caller?
Now I want to address the "uncontrolled descent" theory.
At 14:13:03 VJ592 was at 7,000 ft. flying at 274 Kts.
13 Seconds later, at 14:13:16, VJ592 was at 6,700 ft. and was flying
at 340 Kts.
VJ592 had dropped just 300 ft. and gained 66 kts. of airspeed.
Another 13 seconds pass and VJ592 was at 1,000 and was flying at 405
Kts.
In an identical period of time, VJ592 dropped over 5 times the
altitude (5,700 ft.) but gained less airspeed (only 65 Kts.)
At 14:13:16, as she rolled out of her turn on her assigned heading of
140 degrees, did she extend her flaps in order to keep her speed down
in a deliberate controlled descent? If she wanted to make it to MIA,
she would have kept the aircraft "clean" and poured the coals to it
and been in a shallow descent. She could have been on the ground at
MIA in a little over 3 minutes.
This sounds to me like a very "controlled descent". VJ592 followed
ATC instructions, and rolled out on the assigned headings given to
her. The only mistake we know VJ592 made was the faulty readback of
the altitude and the controller AND his supervisor screwed that up.
When she intentionally busted through her assigned altitude, the
controller and his supervisor failed to ask any questions. Why? I
see no evidence of broken cables here.
This letter and your response will be posted on the Valujet Memorial
Website at www.flight592.com
Sincerely,
James A. Bergqust
Air Safety Activist